WASHINGTON — When a psychiatrist and research fellow at the Yale School of Medicine recently advocated the use of “puberty blockers” for children dealing with gender-identity issues, in an opinion column for The New York Times, a flood of reader comments accused the physician of supporting treatment that amounted to “child abuse.”
Jack Turban, the author of the controversial column and a lecturer on “the treatment of transgender and gender-nonconforming youth,” told the story of Hannah, a patient who is biologically male and has begun “using a puberty-blocking implant and getting ready to embark on the path of developing a female body by starting estrogen.”
“Ten years ago most doctors would have called this malpractice. New data has now made it the protocol for thousands of American children,” said Turban. “Over the past few years, it has become clear that if we support these children in their transgender identities instead of trying to change them, they thrive instead of struggling with anxiety and depression.”
But a report released June 20 in The New Atlantis, “Growing Pains: Problems With Puberty Suppression in Treating Gender Dysphoria,” has comprehensively challenged the same treatment model defended by Turban and many leading experts.
“In light of the many uncertainties and unknowns, it would be appropriate to describe the use of puberty-blocking treatments for gender dysphoria as experimental,” read the report, which states that this new treatment has been offered to children without the usual safeguards that govern the provision of experimental therapies, such as “carefully controlled clinical trials, as well as long-term follow-up studies.”
Paul Hruz, a pediatric endocrinologist and an associate professor of cell biology and physiology at Washington University School of Medicine in St. Louis, is the principal author of “Growing Pains.” The report summarizes the conclusions of 50 peer-reviewed studies on gender dysphoria in children and is co-authored by Lawrence Mayer, professor of statistics and biostatistics at Arizona State University, and Dr. Paul McHugh, professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine who served for 25 years as psychiatrist in chief at Johns Hopkins Hospital. In 2016, The New Atlantis published another article on sexuality and gender that was authored by McHugh and Mayer and challenged key elements of new sexual orthodoxies promoted by “LGBT” activists and their allies in the academy.
“Physicians should be cautious about embracing experimental therapies in general, but especially those intended for children, and should particularly avoid any experimental therapy that has virtually no scientific evidence of effectiveness or safety,” the authors of “Growing Pains” warn.
The American Psychiatric Association’s latest Diagnostic and Statistical Manual of Mental Disorders describes “gender dysphoria” as an “incongruence between one’s experienced/expressed gender and assigned gender.” This experience is accompanied by “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Experts and transgender advocates who support the adoption of puberty blockers for children with gender dysphoria contend that these drugs suppress “the consequences of going through a puberty that doesn’t match a transgender child’s identity,” as stated in a 2016 guide for parents of children with the condition, released by the American Academy of Pediatrics and the American College of Osteopathic Pediatricians. But the “Growing Pains” report calls for more research to establish whether the alleged mental-health benefits, such as lower levels of depression and anxiety, have been confirmed in large peer-reviewed studies and found to be lasting.
In 2007, U.S. clinicians began to use gonadotropin-releasing hormone drugs, also known as puberty blockers or suppressors, to help patients who felt “trapped in the wrong body” and were deeply disturbed by the onset of puberty and its impact on their bodies. In 2008, The Endocrine Society, the nation’s leading professional organization of endocrinologists, specialists who would be charged with prescribing the puberty blockers, approved the use of the drug as a treatment for patients with gender-identity issues as young as 12 years old.
The treatment, introduced in Europe in the 1990s, is designed to prevent the physical changes that normally take place during puberty, like the development of breast tissue and changes in the voice, musculature and facial hair. Advocates say puberty suppressants give young patients time to “explore” their preferred gender and assess their options.
While doctors are permitted to use these drugs in treating children with gender issues, the U.S. Food and Drug Administration has not approved their use for this purpose. “Off-label status reflects that the use has not been proven in clinical trials to be safe and effective,” the “Growing Pains” report explains.
In an interview with the Register, Dr. Hruz acknowledged that children who experience an incongruence between their gender and biological sex are “suffering” and that their struggle poses unique challenges for their parents and physicians. He emphasized, however, that a child’s special vulnerability means that a rigorous evaluation of proposed treatments is even more important.
“The bottom line is that there is very little scientific evidence supporting” this treatment as “safe and reversible. We have no good evidence on the safety and lots of good reasons to worry about the harm.”
The drugs are part of an evolving treatment protocol for children with gender dysphoria that often includes “gender-affirming” therapy, in which the patient’s preferred gender is accepted, rather than challenged.
“Gender-affirming models of treatment are sometimes applied even to very young children,” the report notes.
“Often, the gender-affirming approach is followed in later youth and adulthood by hormonal and surgical interventions intended to make patients’ appearances align more closely with their gender identity than their biological sex.”
Advocates of this therapy confirm that patients prescribed cross-hormone drugs could become sterile. But the report also warns of potential health risks to younger patients on puberty suppressants. The disuption of puberty in children as young as 9 could affect physical growth and bone density, and the authors say more research is needed to study the impact on the developing brain, among other concerns.
Likewise, they state that the lack of sound data on the origins of gender dysphoria, a condition once called "gender-identity disorder," should raise additional questions. Should clinicians recommend a course of treatment when they have so little information about the underlying causes of gender dysphoria and its persistence in a minority of patients?
Indeed, the authors raise the possibility that puberty blockers, combined with “gender-affirming” therapy, may help to solidify the experience of gender dysphoria.
For example, the report notes that an influential 2011 Dutch study on the use of these drugs for children with gender dysphoria also reported that every patient in the study opted to continue with treatment, a sign that their identification with the opposite sex had become more established. In contrast, previous studies found that the condition did not persist in most patients, and “Growing Pains” raises the possibility that this treatment model is sending more young patients on a one-way path.
“Gender identity for children is elastic (that is, it can change over time) and plastic (that is, it can be shaped by forces like parental approval and social conditions),” the report explains.
“If the increasing use of gender-affirming care does cause children to persist with their identification as the opposite sex, then many children who would otherwise not need ongoing medical treatment would be exposed to hormonal and surgical interventions.”
The authors’ observations offer cautionary guidance, as increasing numbers of young Americans explore “gender fluidity,” with Facebook inviting its users to choose among 58 “gender options.” Clinicians who treat gender dysphoria report a surge of children seeking help at younger ages, after Bruce Jenner, the Olympic medalist and reality-show star, announced in 2015 that he now identified with the opposite sex and as public schools debate proposals mandating that “transgender” students be allowed to use the bathroom that matches their preferred gender.
Ryan Anderson, the author of the forthcoming book When Harry Became Sally: Responding to the Transgender Moment, endorsed the release of “Growing Pains” as a needed check on the arguments espoused by increasingly influential transgender activists.
“The best biology, psychology, and philosophy all support an understanding of sex as a bodily reality, and of gender as a social manifestation of bodily sex,” said Anderson in a post on the Heritage Foundation’s Daily Signal site that cited studies showing that patients who had undergone “sex reassignment” surgery are 19 times more likely than average to die by suicide.
“Biology isn’t bigotry, and we need a sober and honest assessment of the human costs of getting human nature wrong,” Anderson wrote. “This is especially true with children.”
“Growing Pains” does not offer a critique of new social and political movements that have challenged the male-female binary or promoted bathroom rights for “trans kids.” Rather, the report grounds the reader in the established science of puberty and biological sex to show why drugs that disrupt the “complex, related, and overlapping physical processes” of puberty should be viewed with utmost caution.
Thus the authors strongly challenge the view of experts who say these drugs are “reversible” and need not have a permanent impact on young patients.
“If a child does not develop certain characteristics at age 12 because of a medical intervention, then his or her developing those characteristics at age 18 is not a ‘reversal,’ since the sequence of development has already been disrupted,” the authors explain.
They note that no major studies have actually evaluated the impact of puberty suppression in patients with this condition, including those who realign their gender with their biological sex, so the claim that the treatment is “reversible” is “based on speculation.”
The New Atlantis report points to the role of LGBT advocacy groups in promoting the adoption of puberty blockers as a “safe” and “reversible” option.
In 2016, “the Human Rights Campaign, an LGBT advocacy group, partnered with the American Academy of Pediatrics — the nation’s most prominent professional organization for pediatricians — and the American College of Osteopathic Pediatricians to publish a guide for families of transgender children,” states the report.
The guide was intended to “prevent the consequences of going through a puberty that doesn’t match a transgender child’s identity,” adding that “health care providers may use fully reversible medications that put puberty on hold.”
These guidelines have upended previous treatment models designed to actively discourage a child’s strong identification with the opposite sex, or others that adopted a neutral posture, with the expectation that the child will ultimately embrace their biological sex — and concerns were expressed.
“Currently there is a vigorous, albeit suppressed, debate among physicians, therapists and academics regarding what is fast becoming the new treatment standard for [gender dysphoria] in children,” read a statement on gender dysphoria issued by another professional organization for pediatricians, the American College of Pediatricians, in August 2016.
Treatment protocols that combine puberty suppressants and cross-sex hormones result “in the sterility of minors,” the professional group stated, while disputing the scientific basis for arguments that present gender-identity disorder as “innate,” and thus fixed.
Increasingly, therapists who don’t adhere to the “affirmative” model have found themselves under fire.
A recent BBC documentary, Transgender Kids: Who Knows Best?, told the story of Kenneth Zucker, a leading Canadian researcher and clinician who encouraged his patients to realign their gender with their biological sex and only approved medical interventions when the initial therapy proved unsuccessful.
In 2015, Zucker was forced to resign from his practice, and, later, transgender activists sought to suppress the airing of the documentary that featured his ideas, among other viewpoints.
News reports and anecdotal evidence suggest that therapists and physicians will face mounting pressure to adopt the “affirmative” model, including the use of puberty blockers. Yet “Growing Pains” seeks to make clear that “the evidence for the safety and efficacy of puberty suppression is thin, based more on the subjective judgments of clinicians than on rigorous empirical evidence.
“It is, in this sense, still experimental — yet it is an experiment being conducted in an uncontrolled and unsystematic manner.”
Will this report prompt experts, like Yale’s Jack Turban, to re-evaluate the guidelines they have adopted and promoted?
It seems unlikely. In his New York Times column, Turban said that even if some studies were right, and the majority of prepubescent children with this condition did change their mind about “being transgender,” he would still prescribe the drugs for patients who might otherwise descend into depression.
Still, he acknowledged that the “effects of cross-sex hormones like estrogen are not easily reversible. The hormones can impair fertility, but transgender teens are offered fertility preservation options before that stage, like freezing sperm or eggs. Surgery, which often follows in young adulthood, is also, of course, essentially permanent.”
Ryan Anderson, for his part, hopes “Growing Pains” will be wake-up call for physicians and parents seeking to help children who believe they are trapped in the wrong body.
“This new article in The New Atlantis,” said Anderson, “should make all of us pause before embracing radical medical treatments for children.”
Joan Frawley Desmond is a Register senior editor.